Newspaper/Magazine Article

Workarounds are prevalent in health care and create opportunities for unintended consequences. This newsletter article discusses how workarounds serve as indicators of system failures and present opportunities to identify and design long-term strategies to reduce risks.

Journal Article > Study

This single-hospital study explored the practice of medication dispensing by physicians. Although physicians were commonly expected to dispense medications, especially in the emergency department, some participants felt insufficiently trained to perform this task.

Journal Article > Study

In this retrospective review of pediatric medication alerts, more than 85% of dosing alerts presented to clinicians were inappropriate. Frequent incorrect alerts contribute to alert fatigue and make clinicians more likely to override appropriate warnings.

Newspaper/Magazine Article

This article reports on errors involving neuromuscular blocking agents (NMBAs) that were reported to Medmarx database, what factors contributed to those errors, and what can be done to minimize their occurrence.

Journal Article > Study

The authors evaluated the effectiveness of computerized alerts in reducing co-prescribing of warfarin and interacting medications. They found that the alerts had a modest impact on minimizing this potentially dangerous behavior.

Journal Article > Study

The authors report a "systems analysis" of the adverse drug events (ADEs) detected in their seminal 1993 study at the Massachusetts General Hospital and Brigham and Women's Hospital, Boston. Using 11 intensive and general care units at the two hospitals, the authors prospectively identified actual and potential ADEs by contemporaneous chart review, provider interview, and voluntary incident reporting. The authors report their analysis of the underlying, or "system," causes of the ADEs as distinct from attributing the ADEs solely to individual provider error. They found the leading cause of error was lack of drug knowledge on the part of the ordering physician, accounting for 22% of errors. Overall, the authors describe 16 system failures leading to ADEs, with seven accounting for 78% of all errors. Using the airline industry as an example, the authors advocate a nonpunitive systems approach as a more effective means of preventing error than approaches focused on the individual.

Journal Article > Study

The root causes of the opioid epidemic are complex, but inappropriate prescribing of opioids (which includes both prescribing opioids in situations where they are not indicated as well as excessive prescribing for appropriate indications) is a major contributor. Prior studies of outpatient antibiotic prescribing have shown that rates of inappropriate prescribing rise toward the end of clinicians' clinic sessions. This cross-sectional study used data from 5603 primary care physicians for acute painful conditions to analyze whether a similar relationship exists for opioid prescribing. Investigators found that the likelihood of opioid prescribing rose considerably as the workday progressed; clinicians were also more likely to prescribe opioids if their appointments were running late. In contrast, prescriptions for nonopioid therapies did not change in relation to appointment time. Although the magnitude of these effects was smaller than the variation in opioid prescribing rates between physicians found in other studies, these findings confirm that production pressure and decision fatigue contribute to inappropriate prescribing and should be addressed in quality improvement efforts to reduce opioid use.

Journal Article > Commentary

This commentary discusses how regulation, misinformation, and cultural beliefs influenced opioid prescribing behaviors for pain management that contributed to the opioid crisis. The author reviews efforts to address the problem, including a comprehensive approach to promote the use of nonopioid analgesics in perioperative care.

Alerts designed to prevent inappropriate prescribing of medications are frequently overridden and contribute to alert fatigue. This study describes the use of machine learning to improve the clinical relevance of medication error alerts in the inpatient setting.

Journal Article > Commentary

Testing process improvements prior to implementation can help identify and address potential unintended consequences on practice. This commentary explores how a quality improvement initiative seeking to reduce the opportunity for mistakes may have resulted in treatment delays.

A key safety feature of electronic health records is computerized provider order entry, which can reduce adverse drug events. This retrospective multisite study used simulated medication orders to determine whether electronic health record decision support detected and alerted providers about possible adverse drug events. The proportion of potential adverse drug events increased over time. Electronic health record decision support identified 54% of adverse drug events in 2009; this increased to 61.6% in 2016. There was substantial variation among hospitals using the same commercial electronic health record vendor, demonstrating the importance of local implementation decisions in medication safety. These findings emphasize the need for further efforts to enhance safety of electronic health records.

Cases & Commentaries

An elderly man admitted for agitation and suicidal ideation was prescribed clozapine by psychiatry. The clozapine Risk Evaluation and Mitigation Strategy (REMS) program requires both prescribers and patients to be registered in an online database. A REMS-registered attending psychiatrist entered the initial order (12.5 mg). During the hospitalization, the medicine intern, who was not registered with the REMS program, titrated the dose to 25 mg daily and also wrote the discharge prescription. The outpatient pharmacist noted the intern was not registered and contacted the attending psychiatrist, who wrote a new prescription. The patient's family was unable to pick up the prescription for 3 days. During this gap in therapy, the patient experienced recurrence of paranoia and required readmission to the hospital.

Medication errors occur frequently in the outpatient setting and can lead to patient harm. A common scenario is one in which a patient is prescribed multiple medications, does not know what each one is for, and takes them incorrectly. Medication safety experts have advocated that prescribers include indications on prescription labels to enable patients and pharmacists to check the bottle in order to remember a medication's purpose. Investigators examined more than 4 million outpatient prescriptions from a single institution and found that only 7.4% of prescriptions included an indication. Medications for symptoms like pain, nausea, and anxiety were much more likely to have indications than medications for chronic diseases. Internal medicine physicians, whose patients are more likely to take multiple medications, wrote indications 6% of the time. A PSNet perspective explored how community pharmacists can use medication indications and other tools to ameliorate medication-related harm.

Book/Report

Inconsistent checking for and consideration of drug allergy alerts can diminish the safety of prescribing. This report from a multistakeholder work group provides evidence-based safe practices and recommendations for improvement, including standardizing documentation practices, actionable decision support, monitoring of alert effectiveness, and patient engagement.